General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14-2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Medtronic.

To evaluate the feasibility, efficacy, and safety of percutaneous vertebroplasty (PV) in the treatment of pathologic fractures owing to malignancy with epidural involvement, with or without neurologic symptoms of spinal cord or cauda equina compression. This study was approved by the local ethics committee; informed consent was obtained from all patients. This retrospective review was performed for 51 consecutive patients with metastatic disease or multiple myeloma treated by means of vertebroplasty, who presented with at least one vertebral lesion with epidural involvement, with or without clinical symptoms of spinal cord or cauda equina compression. All patients with neurologic deficit were terminally ill. A neurologic examination was performed before and after treatment in all patients. All imaging examinations and treatments were reviewed, and chi(2), Mann Whitney, or Fisher exact testing was performed for univariate analysis of variables. A total of 74 vertebrae were treated in 51 patients, 22 women and 29 men with a mean age of 62.5 years (range, 28-85 years). Fifteen (29%) patients presented symptoms of complete or incomplete spinal cord or cauda equina compression before vertebroplasty and no further clinical deterioration was observed after treatment. The analgesic efficacy of vertebroplasty was satisfactory for 94% (48 of 51) of patients after 1 day, 86% (31 of 36) patients after 1 month, and 92% (11 of 12) patients after 1 year. One patient with no clinical neurologic deficit before treatment experienced symptoms of cauda equina compression 2 days after vertebroplasty. No other major complication was observed. The feasibility, efficacy, and safety of PV were confirmed in patients experiencing pain related to malignant spinal tumors with epidural extension, with a low complication rate. PV should become part of the palliative analgesic treatment for such patients. (c) RSNA, 2010.

Background and Purpose—: Basilar trunk aneurysms (BTAs), defined as aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery, are rare and challenging to manage. We describe the natural history and management in a consecutive series of BTAs. Methods—: Between 2000 and 2013, 2522 patients with 3238 aneurysms were referred to our institution for aneurysm management. A retrospective review of this database was conducted to identify all patients with BTAs. Results—: In total, 52 patients had a BTA. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8–86) months, and imaging follow-up was 26 (interquartile range, 2–80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population ( P =0.021). There was preponderance of segmental ectasia or mural bleeding ectasia ( P =0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled. Conclusions—: BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage.

Background and Purpose— In malignant cerebral venous thrombosis (CVT) patients, emergency decompressive surgery has been suggested as a life-saving procedure. We report 12 patients with malignant CVT, among whom 8 underwent operation. Methods— Retrospective study of 12 patients from 3 stroke units who had a malignant CVT as defined: (1) supratentorial cortical lesions attributable to superficial venous system thrombosis with or without sinus involvement; (2) with clinical (decreased consciousness and dilated pupils) or radiological signs of transtentorial herniation; (3) either at onset or after worsening despite heparin therapy. Surgery or abstention was decided individually by neurosurgeons on call. Results— There were 9 women and 3 men with a mean age of 45±15 years. The delay between heparin therapy and signs of malignancy ranged from 2 to 30 hours. At malignant worsening all but 1 patient had hemorrhagic lesions; the median deviation of septum pellucidum was 12 mm (interquartile range, 6.7–13); 5 patients (including 3 who underwent operation) had a unilateral dilated pupil; and 4 (2 who underwent operation) had bilateral dilated pupils. Eight patients underwent surgical decompression, external decompression in 4, both external and internal decompression in 3, and internal decompression in 1. The 4 patients who did not undergo operation died within 1 to 5 days after diagnosis. One patient who underwent operation died of a pulmonary embolism. The 7 others survived, with, at last follow-up (median, 23.1 months; interquartile range, 19.7–45.6), an excellent recovery of mRS 0 or 1 in 6 and mRS 3 in 1. Conclusion— Decompressive surgery may save lives and may even allow a good functional outcome in malignant CVT, even in patients with bilateral dilated pupils.